Provider Demographics
NPI:1942537097
Name:CHINEVERE, STACY MARIE I
Entity type:Individual
Prefix:MISS
First Name:STACY
Middle Name:MARIE
Last Name:CHINEVERE
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAMERON
Other - Middle Name:KADIN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:326 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203
Mailing Address - Country:US
Mailing Address - Phone:517-962-2258
Mailing Address - Fax:
Practice Address - Street 1:326 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203
Practice Address - Country:US
Practice Address - Phone:517-962-2258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI516777585266101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health